Healthcare Provider Details

I. General information

NPI: 1598291023
Provider Name (Legal Business Name): ERICA OGAWA COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 PERIMETER PARK DR
ATLANTA GA
30341-1317
US

IV. Provider business mailing address

3331 ALDEN PLACE DR NE
BROOKHAVEN GA
30319-2967
US

V. Phone/Fax

Practice location:
  • Phone: 770-393-9901
  • Fax:
Mailing address:
  • Phone: 404-993-1784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1999
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: